Philip Okafor

Bio

Bio

I am a gastroenterologist who strives to provide high-quality and exceptional medical care to every patient, every day. My patients always come first, so I focus on listening to them at every clinic visit. This enables me provide care that respects their wishes and yields the best outcomes. My clinical practice involves seeing patients with general gastroenterological conditions. In addition, I care for patients with celiac disease, hereditary colon cancer and polyposis syndromes.

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Research & Scholarship

Current Research and Scholarly Interests

I am a health services researcher who studies variations in access to health care resources, including under- and overutilization of available resources to see how these inequalities impact outcomes. I utilize large database methodologies to identify novel disparities with the goal of finding solutions that will improve health equity for all.

Abstract

INTRODUCTION: There is a lack of data on the impact of readmission to the same vs a different hospital following an index hospital discharge in cirrhosis patients.METHODS: We sought to describe rates and predictors of different-hospital readmissions (DHRs) among patients with cirrhosis and also determine the impact on cirrhosis outcomes including all-cause inpatient mortality and hospital costs. Using the national readmissions database, we identified cirrhosis hospitalizations in 2013. Regression analysis was used to determine the predictors of DHRs. A time-to-event analysis was performed to assess the impact on subsequent readmissions and all-cause inpatient mortality.RESULTS: In 2013, there were 109,039 cirrhosis readmissions with 67% of these being same-hospital readmissions and 33% being DHRs (P < 0.001). Two percent of readmitted patients were treated at ?4 different hospitals. The 30-day readmission rate was 29.1%. Predictors of DHR included Medicaid payer (adjusted odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.01-1.14), age (OR 0.98, 95% CI 0.978-0.982), elective admission (OR 1.09, 95% CI 1.01-1.17), hepatic encephalopathy (OR 1.20, 95% CI 1.16-1.25), hepatorenal syndrome (OR 1.09, 95% CI 1.03-1.16), and low socioeconomic status (OR 1.15, 95% CI 1.06-1.25). No difference was observed in 30-day readmission risk following a DHR (adjusted hazard ratio 1.044, 95% CI 0.975-1.118). In addition, there was no increased risk of inpatient death observed during a DHR within 30 days (adjusted hazard ratio 1.08, 95% CI 0.94-1.23). However, patients with DHR had significantly higher hospital costs and length of stay.CONCLUSIONS: Majority of cirrhosis readmissions are same-hospital readmissions. Different-hospital readmissions do not increase the risk of 30-day readmissions and inpatient mortality but are associated with higher hospital costs.

Abstract

BACKGROUND AND AIM: Optimal rectal cancer (RC) outcomes depend on accurate locoregional staging. The study sought to describe the impact of endoscopic ultrasound (EUS) on RC treatment patterns and survival.METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare database, the study identified patients with RC between 2005 and 2007. The study excluded patients with stage IV disease, those not enrolled in Medicare parts A and B, those enrolled in managed care, and those staged with pelvic magnetic resonance imaging (because of low numbers). The study then compared outcomes between patients who received EUS and computed tomography of the abdomen and pelvis (CTAP) to those staged with CTAP alone after propensity score matching.RESULTS: Between 2005 and 2007, we identified 3,408 nonmetastatic RC patients. Compared with patients staged with CTAP alone, those who received EUS and CTAP were younger (median age: 75 vs 76years, P<0.0001), more likely men (57.6% vs 48.7%, P<0.0001), with a lower Charlson comorbidity index (P<0.0001). Predictors of EUS included socioeconomic status (highest vs lowest) (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.4-2.5), care by a gastroenterologist (OR 1.713, 95% CI 1.38-2.13), and care in a teaching hospital (OR 1.68, 95% CI 1.35-2.08). Receipt of neoadjuvant chemoradiation was higher in EUS-staged patients (50.3% vs 16.0%, P<0.0001). EUS-staged patients had longer overall survival compared with those staged with CTAP alone (60 vs 57months), but this was not statistically significant (P=0.24).CONCLUSION: Endoscopic ultrasound in RC staging is associated with higher utilization of neoadjuvant chemoradiation without a significant difference in overall survival.

Abstract

Intestinal infections are common in patients with inflammatory bowel disease (IBD) and may mimic IBD flares. In this study, we estimate the changing incidence of intestinal infections among IBD hospitalizations and assess the impact of intestinal infections on key hospitalization metrics.The National Inpatient Sample (NIS) was analyzed for hospitalizations from IBD between 1998 and 2014. Intestinal infections were identified using ICD-9-CM codes, and incidence for each infection was calculated for Crohn's disease (CD) and ulcerative colitis (UC). Linear and logistic regression analyses were used to assess the effects of intestinal infections on hospitalization duration, charges, and mortality.There were 4,030,620 hospitalizations for IBD between 1998 and 2014. The annual incidence of intestinal infections rose from 26.2 to 70.6 infections per 1000 IBD hospitalizations (Ptrend < 0.01). A main driver of this rising incidence was Clostridium difficile infections, which increased from 7.8 to 32.1 per 1000 CD hospitalizations and from 23.0 to 84.7 per 1000 UC hospitalizations (Ptrend < 0.01). The incidence of other intestinal infections increased from 10.2 to 15.3 per 1000 CD hospitalizations and 16.5 to 25.3 per 1000 UC hospitalizations. Intestinal infections and particularly C. difficile infections were associated with longer hospitalizations, greater hospital charges, and greater all-cause mortality.The incidence of intestinal infections among hospitalized IBD patients has increased over the past 15 years, primarily driven by C. difficile infections. Intestinal infections are associated with length of stay, hospital charges, and all-cause mortality. More aggressive measures for prevention of C. difficile infections are needed. 10.1093/ibd/izy086_video1izy086.video15779257979001.

Abstract

Secondary analysis of large datasets involves the utilization of existing data that has typically been collected for other purposes to advance scientific knowledge. This is an established methodology applied in health services research with the unique advantage of efficiently identifying relationships between predictor and outcome variables but which has been underutilized for hepatology research. Our review of 1431 abstracts published in the 2013 European Association for the Study of Liver (EASL) abstract book showed that less than 0.5% of published abstracts utilized secondary analysis of large database methodologies. This review paper describes existing large datasets that can be exploited for secondary analyses in liver disease research. It also suggests potential questions that could be addressed using these data warehouses and highlights the strengths and limitations of each dataset as described by authors that have previously used them. The overall goal is to bring these datasets to the attention of readers and ultimately encourage the consideration of secondary analysis of large database methodologies for the advancement of hepatology.

Abstract

We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses.Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race.There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86).African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.

Abstract

Emerging evidence suggests that Pneumocystis jiroveci pneumonia is occurring more frequently in Crohn's disease patients on immunosuppressive medications, especially corticosteroids. Considering its excess mortality and the efficacy of chemoprophylaxis in reducing P. jiroveci pneumonia in acquired immunodeficiency syndrome, there is debate without consensus on the need for chemoprophylaxis in Crohn's disease patients on corticosteroids.We sought to address this debate using insights from simulation modeling.We used a Markov microsimulation model to simulate the natural history of Crohn's disease in 1 million virtual patients receiving appropriate care and who faced P. jiroveci pneumonia risks that varied with corticosteroid use. We examined several chemoprophylaxis strategies and compared their population-level economic and clinical impact using various indices including costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios. We also performed several nested probabilistic sensitivity analyses to estimate the health and economic impact of chemoprophylaxis in patients on triple immunosuppressive therapy.At the current PJP incidence, no PJP chemoprophylaxis was the preferred strategy from a population perspective. Considered chemoprophylactic strategies led to higher average costs and fewer P. jiroveci pneumonia cases. However, they also led to lower average quality-adjusted life expectancy and were thus dominated. Nevertheless, these alternative strategies became preferred with progressively higher risks of P. jiroveci pneumonia. Our results also suggest that PJP chemoprophylaxis may be cost-effective in patients on triple immunosuppressive therapy.Our findings support a case-by-case consideration of P. jiroveci pneumonia chemoprophylaxis in Crohn's disease patients receiving corticosteroids.

Abstract

In May 2014, vedolizumab was approved by the Food and Drug Administration for the treatment of moderate-to-severe Crohn's disease. In clinical practice it is typically used in patients who are primary or secondary non-responders to adalimumab [Humira]. We aim to estimate the incremental benefits and costs of using vedolizumab as rescue therapy for adalimumab non-responders.A Markov model was used to simulate the clinical course of Crohn's disease in a hypothetical cohort of 10,000 patients over a 12-month period. The treatment strategies evaluated were adalimumab only [with and without dose intensification] and adalimumab and vedolizumab [with and without adalimumab dose intensification]. The base case strategy was adalimumab only with 25% of non-responders undergoing dose intensification. Our primary outcomes were changes in costs and quality of life measures over the analytical horizon.In a 1-year period, initiating vedolizumab as rescue therapy in adalimumab non-responders reduces the average total cost per patient by 10%, and increases the average amount of time spent in remission or mild disease by up to 2 months.Treating on-label adalimumab non-responders with vedolizumab can, in the short term, significantly improves the quality of life of Crohn's disease patients that do not respond to adalimumab.

Abstract

During Roux-en-Y gastric bypasses (RYGB), some surgeons elect to perform a vagotomy to reduce symptoms of gastro-oesophageal reflux (GER). Routine vagotomy during RYGB may independently affect weight loss and metabolic outcomes following bariatric surgery. We aimed to determine whether vagotomy augments percent excess weight loss in obese patients after RYGB.We examined the effect of vagotomy in 1278 patients undergoing RYGB at our institution from 2003 to 2009. Weight and percent excess weight loss (%EWL) were modelled at three months and annually up to five years using a longitudinal linear mixed model controlling for differences in age, gender, initial body mass index (BMI), ideal body weight, and presence of vagotomy.Vagotomy was performed on 40.3% of our cohort. Vagotomy patients had significantly lower initial BMI (46.4±6.2 vs. 48.3±7.7kg/m(2), p<0.001), but there were no other significant differences at baseline. The strongest predictor of %EWL over time was initial BMI, with lower BMI patients exhibiting greater %EWL (p<0.001). Age and gender effects were also significant, with younger patients (p<0.04) and males (p<0.002) attaining greater %EWL. Vagotomy had no effect on %EWL in either simple or multiple regression models.Our series suggest that vagotomy does not augment %EWL when performed with RYGB.

Abstract

Gastrointestinal tract cancers account for a significant proportion of the national cancer burden.We sought to explore patient- and hospital-level determinants of palliative care utilization among patients hospitalized with metastatic gastrointestinal tract cancers using a national database.An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, Ninth Revision codes were used to identify hospital discharges associated with metastatic digestive tract cancers and patient/hospital covariates for inclusion in a logistic regression model. Total charges and length of stay were analyzed in a linear regression model.Compared to males, females were more likely to receive inpatient palliative care (adjusted odds ratio [OR] 1.12, P = .002). No difference was seen between white and Asian patients (adjusted OR 1.2, P = .11) or Native Americans patients (adjusted OR 1.4, P = .22). However, relative to white patients, African Americans (adjusted OR 1.13, P = .02) and Hispanics (adjusted OR 1.25, P = .001) had significantly higher odds of inpatient palliative care. Medicare patients were least likely to receive palliative care compared to those with Medicaid or commercial payers. Length of stay during these hospitalizations was longer in African Americans (P = .0001), Asians (P = .0001), and Native Americans (P = .03) compared to white patients. No difference was seen when total charges were compared between white and African American patients (P = .08). Conversely, total charges were higher in Hispanics (P = .005) and Asians (P = .001) relative to white patients.Gender and racial differences exist in utilization of inpatient palliative care among patients hospitalized with metastatic gastrointestinal tract cancers.

Abstract

Several studies have demonstrated an increased risk of nonmelanoma skin cancer (NMSC) in patients with inflammatory bowel disease, with the greatest risk in patients with Crohn's disease (CD). We investigated the cost-effectiveness of NMSC screening in patients with CD.A mathematical model was used to compare lifetime costs, life expectancies, and benefits of NMSC screening in a hypothetical cohort of 100,000 patients with CD. Strategies studied include: (1) Treat NMSC cases as they present and follow affected patients annually; (2) Screen patients with CD annually once they turn 50 years old, treat NMSC cases as they present and follow affected patients annually; (3) Screen patients with CD annually once they start receiving thiopurines, treat NMSC cases as they present and follow affected patients annually; (4) Screen patients with CD annually when they turn 50 years old or start receiving thiopurines, treat NMSC cases as they present, and follow affected patients annually; (5) Screen all patients with CD annually. These strategies were then studied on a biennial basis, accounting for 10 competing strategies.Screening all patients with CD annually proved the most cost-effective strategy with an average lifetime cost of more than $333,000, a quality-adjusted life expectancy of about 26 QALYs (95% confidence interval: 22-29), ICER of $3263/QALY, and led to early detection of about 94% of incident NMSC cases. The next best strategy was screening all CD patients biennially with an average lifetime cost of more than $328,000 with 24.5 QALYs (95% confidence interval: 21-25). Only 47% of new NMSC cases were detected early with this strategy.At a willingness-to-pay threshold of $50,000, screening all patients with CD annually for NMSC proved the most cost-effective strategy.

Abstract

The incidence of inflammatory bowel disease (IBD) has increased over the past several decades with a corresponding increase in the number of patients on combination immunosuppressive therapy including corticosteroids, anti-metabolites and biologic agents. The exact incidence of pneumocystis jiroveci pneumonia (PJP) in IBD patients is unknown but there has been an increase in the number of reports of PJP in IBD patients on combination immunosuppressive therapy.We evaluated the published literature describing PJP infections in IBD patients, as well as other non-HIV cohorts and identified risk factors for PJP infection in this group of patients. Prophylaxis and treatment regimens were reviewed.Corticosteroid therapy, lymphopenia (total lymphocyte count < 600 cells/mm), and age greater than 55 years appear to be risk factors for developing pneumocystis jiroveci pneumonia. In addition, PJP mortality is greater in the non-HIV cohort in contrast to the HIV population. No evidence-based guidelines for primary PJP prophylaxis exist to direct practice for gastroenterology providers.Better surveillance and reporting of opportunistic infections including PJP are needed to elucidate risk factors for acquisition of infection. Gastroenterology providers should continue to evaluate the need for PJP prophylaxis on a case-by-case basis to recognize patients who may benefit from primary PJP prophylaxis. In particular, older patients on corticosteroids, multiple immunosuppressive agents, and patients with lymphopenia should be considered for prophylaxis.

Abstract

Patients with inflammatory bowel disease (IBD) may be at increased risk for pneumocystis jiroveci pneumonia (PCP). Our aims were (1) to determine the incidence and relative risk of PCP in IBD and (2) to describe medication exposures in patients with IBD with PCP.We performed a retrospective cohort study and a case series using administrative data from IMS Health Inc, LifeLink Health Plan Claims Database. In the cohort, patients with IBD were matched to 4 individuals with no IBD claims. PCP risk was evaluated by incidence rate ratio and adjusted Cox proportional hazards modeling. The demographics and medication histories of the 38 cases of PCP in patients with IBD were extracted.The cohort included 50,932 patients with Crohn's disease, 56,403 patients with ulcerative colitis, and 1269 patients with unspecified IBD; matched to 434,416 individuals without IBD. The crude incidence of PCP was higher in the IBD cohort (10.6/100,000) than in the non-IBD cohort (3.0/100,000). In the adjusted analyses, PCP risk was higher in the IBD versus non-IBD cohort (hazard ratio, 2.96; 95% confidence interval, 1.75-4.29), with the greatest risk in Crohn's disease compared with non-IBD (hazard ratio, 4.01; 95% confidence interval, 1.88-8.56). In the IBD case series of PCP cases (n = 38), the median age was 49 (interquartile range, 43-57). A total of 20 individuals (53%) were on corticosteroids alone or in combination with other immunosuppression.Although the overall incidence of PCP is low, patients with IBD are at increased risk. Patients with IBD with PCP are predominantly on corticosteroids alone or in combination before PCP diagnosis.

Abstract

The use of combination immunosuppressive agents is associated with reports of pneumocystis jiroveci pneumonia (PJP). The aim of this study was to determine practice patterns among gastroenterology providers for PJP prophylaxis in patients with inflammatory bowel disease (IBD) on immunosuppressive therapy.An internet-based survey of 14 questions was sent through e-mail to a random sampling of 4000 gastroenterologists, nurse practitioners, and physician assistants between November 2011 and February 2012. Three reminder e-mails were sent to providers who had not completed the survey.The invitation e-mail that contained the link to the survey was clicked by 504 providers and the completed surveys were returned by 123 of them (78% physicians, 11% nurse practitioners, 11% physician assistants). The response rate was 24.4%. Seventy-nine percent of the respondents had managed >25 patients with IBD in the past year, with as much as one-third of all respondents managing >100 patients. Eight percent of the respondents reported patients who had developed PJP on immunosuppressive therapy, 11% reported initiating PJP prophylaxis, mostly for patients on triple immunosuppressive therapy. Prescription of PJP prophylaxis was not significantly associated with the number of years in practice or the number of IBD patients treated. However, providers with patients that had developed PJP were 7.4 times more likely to prescribe prophylaxis (P = 0.01). In addition, providers in academic centers were 4 times more likely to initiate PJP prophylaxis than those in nonacademic centers (P = 0.03). The most common reasons for not prescribing PJP prophylaxis included the absence of guidelines on the benefits of prophylaxis, lack of personal experience with PJP, and the lack of knowledge on the need for prophylaxis in patients with IBD on combination immunosuppressive therapy.The lack of guidelines seems to influence the decision on not to prescribe PJP prophylaxis in patients with IBD. Additional studies are needed to determine PJP risk factors and risks and benefits of prophylaxis.